The Ethics of Ambivalence and the Practice of Constraint in US Psychiatry

Abstract

This article investigates the ambivalence of front-line mental health clinicians toward their power to impose treatment against people’s will. Ambivalence denotes both inward uncertainty and a collective process that emerges in the midst of everyday work. In their commentaries about ambivalence, providers struggle with the distance separating their preferred professional self-image as caring from the routine practices of constraint. A detailed case study, drawn from 2 years of qualitative research in a U.S. community psychiatry agency, traces providers’ response to the major tools of constraint common in such settings: outpatient commitment and collusion between the mental health and criminal justice systems. The case features a near-breakdown of clinical work caused by sharp disagreements over the ethical legitimacy of constraint. The ethnography depicts clinicians’ experience of ambivalence as the complex product of their professional socialization, their relationships with clients, and on-going workplace debates about allowable and forbidden uses of power. As people articulate their ethical sensibility toward constraint, they stumble over the enduring fault lines of community psychiatry, and they also develop an ethos of care tailored to the immediate circumstances, the implicit ideologies, and the broad social contexts of their work.

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Acknowledgments

The author thank the National Science Foundation for funding this study and the clients and staff of the pseudonymous Eastside Services for their generosity. The author is also grateful for the perceptive comments of the peer reviewers as well as Janelle Taylor, Michele Rivkin-Fish, and their colleagues at the University of Washington-Seattle and the University of North Carolina-Chapel Hill where he presented early versions of this paper.

Appendix

Excerpt from Narrative Progress Note, Eastside Services:

Client: Nicole Watkins… I had a meeting with supervisor Linda Martell. We developed a treatment plan to present to the court in an effort to provide Nicole with a realistic treatment program in the community that could keep her from becoming a repeat offender and can be presented to the court in order to avoid her doing some significant time in prison. We came up with the following guidelines which will be put forth in a letter to Attorney Dan Schmidt.

1.

She is to be enrolled in the mental health unit of the Office of Probation and Parole and will be expected to comply with all probation officer’s visits.

2.

Upon release from jail, she will be placed in a residential treatment program for prisoners with drug and alcohol problems.

3.

After completion of the residential treatment program, she will spend 1 year in a room and board facility that has a focus on serving prisoners with drug and alcohol problems. She must indeed reside at this facility which includes spending her nights there.

4.

She is to comply with psychiatric services provided by Eastside Services. These services are to include medication monitoring 7 days a week, 3 of these visits will occurring the Eastside Services office and 4 of them will be home visits by Eastside Services staff. She is to take psychiatric medications as prescribed. She is to be available at the designated appointment times whether it is in the Eastside Services Office or a home visit. She is to allow for money management with dispensation of discretionary income at the Eastside Services’s discretion.

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